Site Visit Report Template

[NAME OF COMPANY/WORKSITE] Site Visit Summary

Site Visit Team Members:
Places and Facilities Visited:
Date(s) of Site Visit:
Type/Number of Staff Interviewed:
Program Staff:
Management:
Employees:
Site documentation/reports/plans gathered: Items for Follow up:

Narrative Summary: I. Introduction

a. Size of workforce b. Type of jobs/industry c. Employee characteristics

II.

Program Administration and Management

a. b. c. d. e. Health program benefits or potential benefits Program implementation and goals Program costs Program eligibility, promotion, and communications Employee committees

III.

Programs and Services

a. Current health, safety and health promotion activities (programs and services) b. Training, education, and support c. Assessment and data management, evaluation, program suggestions

IV. V.

Policies
a. Including specific risk factor or health or safety issue areas

Employee Health Benefits

a. Health promotion benefits b. Health insurance coverage c. Incentives

VI.

Environment
a. Findings from the tool for observing worksite environments (TOWE) b. Barriers and Resources

VII. VIII.

Community Linkages Summary/Overall Impressions

Insert any relevant summary tables, figures, exhibits, or pictures